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r � <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Properly FAC)LlTY JD# —�SERViCE REQUEST fl <br /> TransferlP!ocessing Facility 1 <br /> 8 <br /> OWNER I OPERATOR <br /> CENTRAL VALLEY WASTE SERVICES CHI.CK if i3�trNt AouRt ss <br /> i <br /> Fn; :iY KAME" <br /> CENTRAL VALLEY WASTE SERVICLS <br /> { <br /> Sift ADDRESS �- <br /> HOME Of MAILING ADDRESS (it Diff erant from Site Addrrt551 r �- <br /> i ( <br /> City StArJ= zip <br /> 1-00; CA 95241 <br /> Pttt+r,E APty ri i LAND Usr Api-LicATtoN N <br /> i 209 i 369-62T4USE t EArlir a U 91.151 SWISO 34•AA-001; <br /> pioxi #2 F'' BOS OISTRt,t Lo4A;K.iN <br /> ii } .....__._..........._.... <br /> CONTRACTOR J S........ <br /> . <br /> REQUESTORx <br /> CHECK if t�iLL,il�G. �ACGRr ' <br /> KURT STANDEN J DISTRICT MANAGER _ <br /> 1 BuSINEss NAME PHONE# <br /> ( i i <br /> CENTRAL VALLEY WASTE SERVICES 209)369$274 <br /> HOME Or MAJLtNc.ADDRESS FAx ff � <br /> PO Box 241001 <br /> CITY STATE ZIP } <br /> LOW CA 95241 {• <br /> BILLING ACKNOWLEDGEMENT 1, int? rinhP+strinerl _... .._._....._.-..__._.._...._..___ <br /> property cx business owner, operator tit authorized agent of same <br /> that all Srlt;• ""Ind/or luaj9Ck Sitr,:i4r5; F%-Viw:Nrd wm' rlt tit Tit 0f*-ARIM ',• hirr ItiV !JlargeS i13SO'AaleO wilt: IMS ¢==:;r?;k t,1 <br /> }rki ttv aril C;f kirk:?!J It-me of my business ,i f'itrft.'k 7t't?1':k(iTiY' <br /> t als' certity that f shave l"fepaird tlir" all-pil;avor and ch'v the wofk t.. t'n !?r•rf;r,.?r '1 ,.;tl k:r. 41cil? it'. :tr"cord"Itwo vJlitt .ltl <br /> APPLICANT'S SIGNATURE: '.f : id DATE: <br /> Pt OPIFk1Y I BUSINt:S5 OWNER❑ OPFt RA'TOP I MANAW,. Otrter?Au ir,dr:tzi f.,A�Far © I)Iti{{t{t i'11 A�i{.,{•:{{_- � <br /> pre)of of authorization to sign is roquired <br /> At1THQRt'ZZ&7UON Ti] RELEASE JNFORMATtON: '1'(J1r•i; ,:ii;phc<.iLte 1, the owner of operator of(fie property rc::at,:w at <br /> site address herreby atilhoriin_thr ntlt:»';t<;:t any ;At,,k ati!; .ufi- ,kt_tr1r-•:.t?i,ii t k:akri initr,i ;t•ivironnitnt,aU';Ile lstit sL:1erk.n1i.:rrn.�kiC:r? <br /> to tt'r:° art..:P^i;lr:C;•+ iht17 E.KJt{t IS?' :t::scrt;.ri a!r .t it ay.i,'able•and at lilt s-'►tne time if i pfovf!li'Li t;;n%r ai <br /> rtiy rt:{?ri.`.+;rif;ltsM•r+ <br /> TYPEOr SERVICE.REOUFSTEO: RFl AWKWUMENI 10 WCLUDE WOOD CHIP COLONJNG AND IRANSKER OPERATIONS AS V; 4,L AS 60. <br /> ___ .............___._......___._,.. .. <br /> COMMENIS: <br /> Ft& @)I <br /> ff1AW i <br /> �IglHlt�fflt'ACIYIiIIf ' <br /> AcCEPTErl 8"r' EMPLOYEE 9: i DAiF; <br /> AS5.6NE4 TU: EMPLOYEE 1 DAiF: <br /> SruyiC:COL:.'' <br /> . Dare Service Completed (if already conrDieted): � PIE. <br /> }Ce Amount- 6.4 .•.trtuuiri Paid /� Payment 0310 .. . <br /> Payment Type -^• invoice is M Check# Receded By. <br /> y yp ,� 10$ LQ 150 ...... . .x. . <br />